Provider Demographics
NPI:1275144081
Name:WILSON, MARK L JR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 E WASHINGTON ST STE E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2661
Mailing Address - Country:US
Mailing Address - Phone:317-622-2467
Mailing Address - Fax:
Practice Address - Street 1:10609 E WASHINGTON ST STE E
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2661
Practice Address - Country:US
Practice Address - Phone:317-622-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health